38226
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Medicare Pricing
Work RVU
0.77
Facility
$33.73
Non-Facility
$33.73
Documentation Required
- "Humana and subsidiaries follow the Medicare requirements that only allow coverage and payment for services that are reasonable and necessary for the diagnosis and treatment of illness or injury" (i.e., medical necessity must be documented).
- "Humana and subsidiaries apply a Medicare Administrative Contractor's (MAC's) LCD to all requests (both Part A and Part B services) within the MAC's applicable geographic jurisdiction." (Documentation should meet the applicable MAC LCD/NCD requirements.)
- For autologous stem cell harvest and short-term storage in multiple myeloma: "the treating physician documents that a future transplant is highly likely."
- Requests for allogeneic hematopoietic cell transplantation for primary refractory or relapsed Hodgkin and non-Hodgkin lymphoma with B-cell or T-cell origin must meet the criteria contained in the referenced CMS Local Coverage Determinations (L39396, L39398, L39270, L39434, L39477, L39513) — documentation should satisfy those LCD criteria.
Key Coverage Criteria
- Multiple myeloma (stem cell transplantation referenced under CMS NCD 110.23)
- Neuroblastoma (stem cell transplantation referenced under CMS NCD 110.23)
- Non-Hodgkin's lymphoma (stem cell transplantation referenced under CMS NCD 110.23)
- Allogeneic hematopoietic stem cell transplantation (Allo-HSCT) for: Aplastic anemia
- Allogeneic hematopoietic stem cell transplantation (Allo-HSCT) for: Leukemia
- Allogeneic hematopoietic stem cell transplantation (Allo-HSCT) for: Myelodysplastic syndromes (MDS)
2 Active Policies
HUMANA-CHIMERIC-ANTIGEN-RECEPTOR-CAR-T-CELL-THERAPY-MA — Chimeric Antigen Receptor (CAR) T-cell Therapy - Medicare Advantage
HUMANA-HEMATOPOIETIC-STEM-CELL-TRANSPLANTATION-MA — Hematopoietic Stem Cell Transplantation - Medicare Advantage
Related Codes
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